Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

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Friday, December 21, 2007

Dear Readers,I have posted before on the fact that we are running out of specialists, especially here in podunkville. I opined in previous posts, that this problem will only get worse as less and less people decide to put themselves through the 6-10 years of minimum wage 120 hour week hell that is surgical residency. Here's a little article sent to all us car-crash physicians. Sucks to be right all the time.

U.S. hospital EDs increasingly unable to find specialists.In a front-page story, the Washington Post (12/21, A1, Lee) reports, "Hospital emergency departments (EDs) across the United States, already struggling with overcrowding and growing patient loads, are increasingly unable to find specialists to help treat seriously injured and ill patients," say some medical experts. According to one "nationwide survey by the American College of Emergency Physicians in 2005, the most recent available," among the "1,328 emergency department directors who responded, 73 percent said they had a problem with inadequate on-call coverage by specialists, including neurosurgeons, orthopedic surgeons and obstetrician/gynecologists." Centers for Disease Control and Prevention (CDC) statistics indicate that the "annual number of visits to emergency departments rose 18 percent, to 110 million, from 1994 to 2004." However, "the number of hospitals operating 24-hour" EDs "fell by 12 percent" during that time. Experts say that the "shortage of specialists is the result of a fear of malpractice lawsuits, a reluctance to go without pay when seeing uninsured patients, and a growing intolerance for the disruption in their personal lives and private practices."

One reason I'm staying at my current job is the specialty coverage. They're not always friendly or happy to be called, but they're there.

I'm getting hosed by my CMG for 30% plus additional fees. But in my last job, I had no ophtho, no OMFS, limited ENT, and no neurosurgery 40% of the time. Plus, the general surgeons covered "trauma call" but often were across town in surgery at the other hospital when I needed them. I had two people in one month needlessly bleed to death (one from liver/spleen injuries, the other pelvic and femur fractures). Both laid in my department for over 2 hours while I tried to get specialists to come in and tried to get them transferred to a referring hospital (closest was a 2 hour flight away).

There's no helpless feeling like that and I knew I had to get out of there.

Contrary to what you might think, that community actually had very good doctors. But they got tired of being on call, seldom getting paid for the disruption it caused in their lives, and the malpractice burden they had to carry because they cared for acute injuries. The ophtho, OMFS, and ENT were all making enough money in their clinics and could do their elective procedures at an outside surgery center...so they didn't need to be on the medical staff.

The one neurosurgeon who stopped taking call simply made an agreement with the town's other hospital to bypass the bylaws and allow him to be on staff without taking call. So he resigned his privledges at our hospital and did his volumes of elective cases only at their institution. He was a great guy, and a tremendous surgeon. But as soon as he stopped taking call and only did elective neck and back procedures, his malpractice insurance dropped by almost 100K a year. He figured that in the previous year, he had only made about 20K by his on call activities, therefore he chose the pay increase and significant lifestyle boost.

If you tried to force a "fix" such as making these guys take call in order to maintain their medical license...a lot of them would just retire.

There has to be a financial incentive that outweighs lifestyle, and there has to be malpractice relief for the problem to begin to fix itself.

BTW: on the "good news" front, our hospital has notified the vampirish scum sucking butt-fucking, lying, cheating, sons-of-bitches otherwise known as our CMG that they will not renew their contract next December! The hospital is going to deal with us directly, so that's a good start. We'll see where it leads..........

I work at an academic medical center and we run the physician to physician OB/GYN consult service which gives small community/rural hospitals specialty consulting advice 24/7. Our docs get a *lot* of calls from hospitals that just can't keep enough specialists on call...as well as transfers from rural to our hospital. not getting paid for ER consult services has been a problem though at times

here's what would be great anonymous. come into my ER the day before i quit, which will be soon, mostly because of asswipes like yourself. come in and i'll intubate you with paralytics only and i'll keep you paralyzed, awake, and on the vent for a few hours. we will need to put a catheter in you too, if you are a man then we might have difficulty finding your penis but we will try our best. in the meantime, if you do not succeed in getting a really big kidney stone, kindly go fuck yourself.

gentlemen, do we block the anonymi or do we continue to let them post? i kinda like the gratuitous profanity and revenge fantasies.

I can't gather much sympathy for rich doctors. Sorry. Everyone has hassles at work and often make a lot less money. deal with it. I read these blogs for the anectodes. Not for self-indulgant rants about your poor lot in life.

dear anonymous, i'm writing this slowly because i know you don't read fast. the point of this particular post is to warn potential patients that amongst all the 'crises' in health care that are talked about daily on the news the thing that is not being talked about is that young, bright students are not choosing medicine anymore. nor are young bright doctors choosing to do the time to become specialists. i am not talking about me. i chose ER medicine because i knew i could not do a surgical residency because of it's incredibly demanding training.

now, specialty surgeons are vanishing and the result will not impact ME, you idiot, because i will always know how to get the care i need for me and my family, but YOU, sir or ma'am, will likely be out of luck in about ten years if you need an aortic graft, bypass surgery, brain surgery, or a penis reconstruction. you remain, an idiot, and deserve to learn about this reality by having it impact on you or your family directly.

you think with the depth of a puddle after a brief shower, and seem to equate money with happiness. best of luck with that.

No, don't block the annons yet. It helps to contrast against the thought that goes into our posts.

So this anon supposedly makes 400K a year. Doesn't say how. I suspect what ever it is, it's a lot easier than what I do for a living! Sure, I'd like to get paid more...wouldn't we all? That's not the beef in this post...it's about the lack of subspecialty back up due to government involvement, lawyers, and economic pressures.

I'm so tired of the "rich doctors" comment. If the 400K person thinks I'm rich, then he can take a massive pay cut and come do my job for a while.

If this dumbass had read the posts carefully, maybe he'd be concerned that in many parts of the country, his 400K a year wouldn't save his children if they needed a subspecialist rapidly. Then he'd really cry a river.....and sue me and my hospital and all of the other "rich doctors" who didn't care and couldn't pull a miracle out of their asses.

Anonymous sounds like someone I know. She has two sons, 40 and 37 respectively; neither has ever held a job for greater than two weeks. Both of her sons have children (a total of 4 grandchildren) which the general public assistance program supports. They attempt to "sue" at any opportunity; in fact I think they expend more energy attempting to sue various people than the energy they would expend actually doing a job.

They whine and cry about how much doctors make so that's the reason they need to be "brought down a peg or two." Of course, since none of them went to a school that demanded 10 years of your life and the total cost of that higher education was probably greater than $300,000.

911doc and any others,So i switched out of EM residency into radiology...funny thing is i actually miss the er. Would i be crazy to go back? From what i read on this blog, i'm not sure i could handle em for 20 years. Is the real world of em that bad? Any advice?

"I love my job. I love the kiddies. I love my job. I love the kiddies..." That's the mantra I go to work with.

Do I love the parents? Not so much. The environment? Not so much, either. Having to deal with a neurosurgeon who leaves me with zero neurosurg coverage (even for trauma) when he goes on vacation? Ouch. No OMFS and minimal ENT (so we flog Plastics endlessly)? Painful.

You still wouldn't find me anywhere else, though. But I'm young; I've only been in the ED real world a few years. It just gets harder and harder to treat patients as the specialists get fewer and farther between.

I can't gather much sympathy for rich doctors. I think this is a jealousy thing. Anon probably hates all wildly successful people. I'm not a doc, but I write about them extensively, and there isn't an interview I've had with a doc where I didn't come away grateful that they made damn good money. They've earned every f*&^ing dime.

dear voxel. do what you think you can do for a career. speak with your program directors... see if you can combine the two in a five year program... you would then be invaluable in both radiology and in emergency medicine. now that would be cool.

voxel: It's hard for me to give advice to young people these days. I don't know what is going to happen to medicine.

No matter how much we all scream to the rafters, it's clear that the government will involve itself more and more in medicine.

Even though most docs make far less than the dick-breathed bottomfeeding malpractie attorneys, and less than the hospital adminstrators (I make 1/5of what the CEO of our hospital makes), we're "the rich doctors" and everyone's gunning for every dime you earn.

It's difficult to tell young people to sacrifice and pay several hundred thousand dollars for 8 years of college and med school, then spend 3 to 5 years making less than minimum wage in residency all for the ultimate reward of making about what a long haul trucker can make.

And if insurance companies, state and federal governments, and hospital and clinic admistrators have their way, that's about what you'll make.

If I was presented with your situation, and I had the choice to switch out of ER and into Radiology, I think I would do it.

I was well advised when I changed from Internal Medicine to Emergency Medicine, and I still think I made the right choice for the time...but in the early '90's, the ER wasn't the dumping ground and litter box that it has become.

The shifting of nights to days and back again with a day "off" inbetween is just hell on your body after a few years. I never know what day of the week it is, and I have to keep my watch on military time so that if I'm in a windowless room (like an ER) I know whether it's AM or PM.

In radiology, you don't have the 500 pound patients with belly pain and a vaginal discharge. No one greater than 350 pounds will fit on your tables.

No good radiology group works all night anymore. They go home at 9 or 10pm on their late nights. Then, they contract with one of the reading services until the next am.

Radiology can have one guy on for the holidays, or can have the reading service cover for them. So you don't get stuck working every damn holiday of the year.

Radiology has lots of cool toys, and if you want to preserve the exciting "life-saving" cases that I occasionally see between snotty noses and chronic back pain, then you can train as an interventionalist. Those guys are awesome.

So, if I had it to do all over again, and everything was the same as it is now...I'd go to Rads. But after Hillary fixes everything for us, who knows...I might just apply to be a diener for Etotheipi.

I don't know how you can tell us without revealing too much of your privacy, but I don't know any EM doc that makes that much just in the practice of EM..Perhaps you have a sideline??

And for 85..I'm sorry you've grown that unhappy about your previous counsel. But I know, and so do you, that there's nothing else you could be but an EMERGENCY PHYSICIAN..SO, HTFU!!!!!! U f^cking Aggie pussy..

Like I said.....I was well advised when I made my change from IM to EM.

But, the ED has taken a decided negative turn in the last 15 years. Sure, it's always been the "dumping groung", but it just seems to get worse daily.

Today, I had an insured patient sent by his PCP's receptionist because he needed a "cervical neck study". She even wrote me an Rx so that I could get it right.

Nevermind that the patient was seen in the ED the night of his accident a week ago and had NO neck pain. Nevermind that he was appropriately evaluated by one of my partners that night.

He began to have some neck stiffness a day later, so when he tried to see his PCP as he was instructed, the f**king receptionist told him the he needed a "cervical neck study".

After waiting 2 hours to be seen, on exam, the patient was like an owl turning his head to watch me as I moved about the room. Clearly his neck (even his 'cervical neck') was fine. But they were insistent that he have the study that the receptionist felt necessary. So he got negative x-rays.

As is my habit, I apologized to the patient and told him that his doc could have easily ordered the study as an outpatient saving him loads of time and money, but that his doc was being lazy and pawning him off. (As said in previous posts, I'm tired of covering for these lasy "go to the ER" SOB's).

I don't know. It just seems to be so much more BS in the ER today than in years past. Our ED alone has gone from a 20K to a 65K volume in the past 10 years.

Last week, had a lady with a couple of months of "burning tounge". She said, "it's just easier to come to the ED than make an appointment with my PCP".

So on one hand business is good for business, but on the other, I'm wearing myself out (as is everyone around me).

BTW, takes a lot of guts for someone from TCU to call an Aggie a pussy.....but since you're twice as tall as me, I'll let you slide on it this time!

erdoc85, agreed. decreased ERs, less capable clinicians in town, vanishing specialists. i could see the circadian problem before and during residency, but never did i imagine that i would become, along with my partneres, THE ONLY docs in town who do 'sick' of any kind (the cardiologists DO take care of the cardiac sick, but our pulmonologist rarely comes into the hospital after regular hours... his PA does). j